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  IEEE TRANSACTIONS ON ENGINEERING MANAGEMENT, VOL. 46, NO. 3, AUGUST 1999 279 Assessing Technological Barriers to Telemedicine:Technology-Management Implications David L. Paul,  Member, IEEE  , Keri E. Pearlson, and Reuben R. McDaniel, Jr.  Abstract— Telemedicine, the use of information technology todeliver health care from one location to another, has the potentialto increase the quality and access to health care and to lowercosts. This growth of telemedicine installations is occurring evenas the utilization rates for installed telemedicine projects arefalling well below expectations. Drawing on data collected fromthree operational telemedicine projects involving different clinicaltelemedicine applications, we examine how the technologicalbarriers to telemedicine are impacting telemedicine utilizationrates. Addressing technological barriers is a necessary but notsufficient condition if telemedicine is to fulfill its promise, andit is predominantly only after such barriers are addressed thatthe other barriers—professional, legal, and financial—come tothe fore. Our findings support end-user and technical training asmajor barriers but do not support the quality of the video, systemreliability, or the perceived inconvenience for physicians to usethe equipment as barriers to telemedicine. The mismatch betweenthe sophistication of the technology and end-user requirementsfor clinical activities and patient confidentiality and privacy issueswere supported as barriers, but how they impacted telemedicineutilization was different than expected. Finally, unsatisfactorysound quality of the telemedicine equipment was identified as afrequent and unexpected barrier to telemedicine utilization rates.  Index Terms—  Medical informatics, technology management,telemedicine. (T)he emphasis placed on high technology systems with-out sufficient consideration of the specific clinical andhealth care requirements and infrastructure capabili-ties in each setting has created a poor fit betweentelemedicine system design and end-user needs [1, p.70]. T ELEMEDICINE, the use of information technology todeliver health care from one location to another, has thepotential to increase the quality and access to health care andto lower costs [2]–[8]. It has been earmarked as a strategiccomponent of the National Information Infrastructure [2], [3]and is at the center of Department of Defense plans to providebetter health care to its remotely located active forces [9] andrevamp its network of veterans hospitals [10].In the United States, at least 35 federal organizations wereinvolved in telemedicine projects, and between 1994 and 1996,the federal government provided over $600 million to fund Manuscript received July 15, 1997; revised September 2, 1998. Review of this manuscript was arranged by Guest Editor A. Reisman.D. L. Paul is with the Robert Emmett McDonough School of Business,Georgetown University, Washington, DC 20057 USA.K. E. Pearlson and R. R. McDaniel, Jr. are with the Department of Management Science and Information Systems, Graduate School of Business,University of Texas, Austin, TX 78705 USA.Publisher Item Identifier S 0018-9391(99)05980-2. telemedicine projects. Over 400 rural health care facilitiesin 40 states were involved in telemedicine projects in 1996,and another 500 facilities expected to be offering telemedicineservices over the next few years [5].I. D ISAPPOINTING  T ELEMEDICINE  P ATIENT  V OLUMES The reported low utilization, clinical and nonclinical,[of installed telemedicine projects] in the face of abun-dant equipment and substantial financial commitment, ispuzzling [5, p. 58].This growth of telemedicine installations was occurringeven as the utilization rates for installed telemedicine projectswas falling well below expectations. Over 65% of the ruralhealth care facilities equipped for telemedicine averaged justover eight clinical telemedicine sessions per month [5]. Overallsystem usage, which includes administrative and educationalapplications as well, averaged fewer than 16 sessions permonth for 70% of the facilities [5].Technological barriers are often cited as a significant causeof the disappointing telemedicine adoption and utilization rates[2]–[4], [6]–[8]. Technological barriers are those instanceswhere the use of the technology is perceived as not beingsufficient to perform the tasks or accomplish the objectivesfor which the technology was initially utilized. They includeuncertainty about the adequacy of a system to support clinicalactivities, system reliability, ease of use, and concerns aboutpatient privacy and confidentiality using an electronic medium[2]–[8], [11]. Drawing on data collected from three operationaltelemedicine projects involving different clinical telemedicineapplications, we examine how the technological barriers totelemedicine are impacting telemedicine utilization rates. Wefocus on telemedicine clinical activities involving consul-tations (teleconsultations) between health care professionalslocated at different health care facilities in order to understandhow technology barriers inhibit their ability to provide healthcare via telemedicine.Addressing technological barriers is a necessary but notsufficient condition if telemedicine is to fulfill its promise, andit is predominantly only after such barriers are addressed thatthe other barriers come to the fore. Reducing technologicalbarriers to telemedicine is by itself unlikely to result in majorincreases in telemedicine adoption and utilization rates becausenumerous other barriers—professional, legal, and financial[2]–[8], [11]—would still exist. Legal and financial barriers arelikely to be primarily administrative in nature. However, theprofessional barriers will involve changing the institutionalized 0018–9391/99$10.00  󰂩  1999 IEEE  280 IEEE TRANSACTIONS ON ENGINEERING MANAGEMENT, VOL. 46, NO. 3, AUGUST 1999 nature of expertise and values of professional life [12]–[14].It should be noted that the utilization of telemedicine isdriven not only by the presenting problem, but also by newopportunities that become apparent only after initial uses of thetechnology have been explored. Information technology oftenhas the property that its utilization drives demand rather thandemand driving utilization [15]. However, understanding howtechnological barriers inhibit the utilization of telemedicine isimportant because technological barriers were largely respon-sible for the failure of the first wave of telemedicine projectsin the 1970’s and early 1980’s [4], [7].The next section provides a brief overview of telemedicineand the technology barriers faced. The methodology used inthis study is then covered. Our findings are presented, and thetechnology-management implications of our findings are thendiscussed.II. T ELEMEDICINE Telemedicine is broadly defined as the use of informationtechnology to deliver health care services and informationfrom one location to another, geographically separated location[1], [2], [4]–[7]. The second wave of telemedicine is in itsemergent phase, as indicated by the relatively short duration of operational telemedicine projects. Over 40% of the operationaltelemedicine projects had been in existence for less than twoyears [5].While there is much disagreement about definitions, 1 telemedicine generally involves three major areas: tele-consultations; teleradiology; and distance learning. Bothteleradiology and distance learning are excluded in thisresearch. Distance learning, the use of information technologyto provide education by linking educators with geographicallyseparated students [7], is excluded because it does notgenerally involve the clinical use of the technology, whileteleradiology, the transfer of radiographic images from onesite to be read at another location [4], [7], is excludedbecause it has been widely accepted and the technologicalbarriers have been largely overcome. Further, the process inteleradiology is very different than that of teleconsultations,as human interaction in teleradiology is minimal and thetechnology involved, asynchronous file transfers, is lesscomplex. This study does not, however, exclude the transferof radiographic images using the video cameras that are partof videoconferencing and specialized telemedicine systemsbecause image quality sufficiency has yet to be establishedand because these images can be important in the telemedicalclinical consultations.  A. Teleconsultations: Clinical Applications of Telemedicine A teleconsultation, or telemedical consult, is a consultationbetween two or more geographically separated physiciansconnected through the use of information technology [4], [5],[6], [7]. Generally, a teleconsultation is between a family 1 There is not a generally agreed-upon definition for telemedicine, withmost of the controversy centering around what activities are included intelemedicine, and whether the term telemedicine or telehealth should be used.See [1], [4], and [5] for more details.TABLE IT ELECONSULTATION  S PECIALTIES  A VAILABLE practice physician located at a local hospital or clinic and therelevant specialist or subspecialist, who is a member of theclinical faculty at a university-affiliated health sciences center(HSC). The patient or patients may or may not be presentduring the teleconsult. Table I exhibits the clinical activitiesincluded in teleconsultations.  B. Technology in Telemedicine From a technology standpoint, telemedicine is the applica-tion of telecommunications and computer technologies that arealready in use in other industries [1], [2], [4]–[7]. The tech-nology includes the hardware, software, and communicationslink of the telemedicine project. The technology infrastructureis a telecommunications network with input and output devicesat each connected location. Table II summarizes the range of technology used in telemedicine.Both the most simple and complex technologies involved intelemedicine have been excluded from this study. Telephonesand faxes are excluded because they are widely accepted andinvolve no major technology-management issues. Technolo-gies such as robotics and virtual gloves, used in telesurgeryand virtual examinations, are excluded because they are notcurrently deployed in ongoing telemedicine projects and areunlikely to become a standard component for a number of years. 1) Technology Barriers—Technological Capabilities VersusClinical and End-User Needs:  Potential technology barriersto telemedicine include whether the technological capabilitiesof the equipment are sufficient to meet clinical requirements[2], [4], [7] and whether features related to using the tech-nology inhibits health care professionals from engaging inteleconsultations [1], [2], [4]–[7]. One potential technologi-cal barrier concerns the quality of video images transmittedbeing sufficient to meet the clinical needs of the health careprofessionals [3], [4], [5], [7]. Teleconsultations often requirephysicians to examine transmitted radiographic images, yetthe video cameras used to transmit the images do not meetthe minimum resolution standards for digitized radiographicimages set by the American College of Radiology, 2 nordoes the teleconsultation equipment include digitizing scannerscapable of transmitting such images [4], [5]. Another concern 2 These American College of Radiology has set standards of 2000 2   2000pixels per square inch for mammographies and 1000 2   1000 pixels per squareinch for all other digital radiographic images. These standards are for alldigitized radiological images and not just teleradiology.  PAUL  et al. : ASSESSING TECHNOLOGICAL BARRIERS TO TELEMEDICINE 281 TABLE IIT ELEMEDICINE  E QUIPMENT  A VAILABLE is the sufficiency of real-time continuous motion images whenteleconsultations involve illnesses or injuries where motion isneeded to make diagnosis or monitor patient progress, andwhether the images resulting from the use of peripherals aresufficient [2], [3], [4], [7].Other potential technological barriers center around theability of health care professionals to use the equipment[2], [5], [7]. The technological sophistication of health careprofessionals vary, and rural health care professionals, theprimary users of the technology, are perceived as being theleast technologically proficient [5]. Further, physicians maybe reluctant to admit they do not know how to use thetelemedicine equipment. End-user training is needed to over-come these barriers, but end-user training is difficult, especiallyfor rural health care professionals [2], [7]. Insufficient end-user training of both the rural health care professionals andthe specialists at the health sciences centers has the potentialto be a significant barrier to teleconsultations.The inconvenience of using the telemedicine equipmentis also a potential barrier [2], [7], [11]. Teleconsultationequipment at health sciences centers is often located at atelemedicine studio, which is some distance away from thephysicians’ offices and inconvenient for them to use. Desktopteleconferencing units would solve the inconvenience prob-lem, but concerns about their image quality abound [2], [7],[11]. Lastly, the perceived vulnerability of electronic patientrecords and the teleconsultation transmission to unauthorizedaccess provides another technological barrier to engaging inteleconsultations [1], [2], [4]–[7]. The next section presentsour methodology for researching how these barriers impactteleconsultation utilization rates.III. M ETHODOLOGY Three telemedicine projects, each involving a health sci-ences center and a rural health facility, were researched.Multiple case studies, relying on semistructured interviews of key informants, were used in this research. The case studymethod is used when:A how or why question is being asked about a contem-porary set of events over which the investigator has littleor no control [16, p. 9].Case studies are in-depth studies of a few instances of thephenomenon of interest geared toward providing the thick description required to understand and explain emerging phe-nomenon [16]–[18]. Multiple cases can provide the researcherwith an even deeper understanding of the phenomenon of interest, and validity and generalizability can be enhancedthrough the replication of results using multiple cases [16],[18]–[20]. Further, while controlled observations of a controland treatment group may not be possible, the deliberateselection of cases can result in natural controls [16]. Therefore,this research project used the multiple case study design.  A. Sample Three teleconsultation projects were researched. Given theemergent nature of telemedicine, literature on specific clinicalteleconsultation applications is scarce and the literature thatdoes exist often focuses on different aspects of teleconsulta-tions, making across similar clinical application comparisonsdifficult [4], [7], [21]. To overcome this limitation, our sam-ple included teleconsultations that make up the majority of the situations: primary care physician to multiple specialists;specialist to specialist; specialist to patient; and specialistrelying on technology to nonphysician primary care provider.Each project involved a telemedicine relationship between anHSC and a rural health care facility. Telemedicine projectsinvolving health sciences centers were selected to be partof the sample because they are involved in the majority of   282 IEEE TRANSACTIONS ON ENGINEERING MANAGEMENT, VOL. 46, NO. 3, AUGUST 1999 TABLE IIIS ITE  I NFORMATION nonmilitary telemedicine projects [4], [5], and they providea means of natural control of nontechnological barriers toteleconsultations. Health sciences center had the benefit of not having a number of the legal, cultural, and financialbarriers associated with teleconsultations. Licensure was notan issue as our sample included only intrastate telemedicine,and liability issues were minimized because the physicianswere covered by the HSC’s umbrella liability policies and wereengaging in HSC-sanctioned telemedicine projects, minimiz-ing their personal risk. The HSC’s in this study had embracedtelemedicine, and physician participation in these telemedicineprojects was voluntary, reducing cultural issues. The cost of the systems and the telecommunications link had already beenfunded, usually through grants, eliminating cost considerationsas a barrier to utilization during the time these projects werestudied. The physicians at the HSC’s were not reimbursed fortheir teleconsultations; however they were employed by thestate and paid a salary. Further, each HSC was charged in itscharter to improve the access and quality of care of the ruralpopulation in their respective states.Each of the telemedicine projects had to be operational fora minimum of six months to allow the inevitable technologicaland procedural bugs to be addressed and to allow the noveltyof telemedicine to pass. Each of the sites was connected bya T1 line. Site I used VTEL equipment, and the primarilyclinical activities involved pediatric oncology and infectiousdiseases. Site II used PictureTel equipment initially to screenand follow up with oncology patients undergoing bone marrowtransplants. Site III used a system it designed and built itself to provide access to multiple medical specialties. Table IIIprovides a summary of information about each site and itsteleconsultation activity. 1) Site I—Pediatric Oncology/Infectious Diseases:  Site Iwas located in the southwestern part of the United States.The telemedicine project began in 1995 and involved a localhospital approximately 200 mi from HSC I. The teleconsultsinitially focused on monitoring pediatric oncology patients. Aninfectious diseases specialist was located at another facility andinitially once a week drove 45 min to the main HSC I campusfor telemedicine consultations. A VTEL desktop videoconfer-encing unit was installed in the specialist’s office in 1996. Thetelemedicine equipment at the rural hospital was located in thehospital’s conference room, which was used for activities otherthan telemedicine. The rural hospital had recently receivedanother telemedicine unit, which it had installed in the clinicalarea of the hospital. This equipment was not connected to thenetwork at the time of the researchers’ visit. 2) Site II: Oncology—Bone Marrow Transplant:  Site IIwas located in the western part of the United States. Thetelemedicine project became operational in Fall 1996. Itinvolved a private oncology clinic approximately 300 mifrom HSC II, and the bone marrow transplant unit at HSCII, which was ranked as one of the top ten in the UnitedStates. Bone marrow transplant procedures require a one tothree month stay in isolation at a hospital and cost between$40000 and $120000 per patient (depending on the type of transplant performed). Prior to telemedicine, the clinic sentapproximately half its bone marrow transplant patients toHSC II, and the rest to a facility in another state that wasequidistance from the clinic. In addition, once a month a bone
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